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AdultOrthodontics



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Adult Orthodontics

Adult orthodontic treatment is the one thatis specially targeting post- adolescent

patients.It also includes tooth movement carried

out to facilitate other dental procedures

necessary to control disease andrestore function.

has been the fastest growing area in

orthodontics in recent years.



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Two groups of adult patients:

Young adults

• who desired but did not receive

comprehensive orthodontic treatment asyouths

Older Adults

• who have other dental problems receiveadjunctive orthodontic treatment to makecontrol of dental disease and restoration

of missing teeth easier and more effective.



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HISTORY OF ADULT ORTHODONTICS

Kingsley (1880 ) indicated an earlyawareness of the orthodontic potential foradult patients and stated that there are

hardly any limits to the age when movementof teeth might not succeed.

• Differences between tooth movement in

adolescent and older patients.

• Results become more and more doubtful withadvancing years when a considerablenumber of teeth are to be moved



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MacDowell (1901) considered the age after 16years as Impossible age. Believed complete and

permanent change cannot be accomplishedsuccessfully except in cases of rare exceptionsowing to

• development of the adult glenoid fossa

• the density of the bones

• less adaptability of muscles of mastication.



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Lischer (1912) considered the period fromthe sixth to the fourteenth year i.e. time in

an when a change from the temporary to thepermanent dentition takes place as theGolden age of treatment.

Case (1921) demonstrated the value ofadult orthodontic therapy for patient withpyorrhea in the lower anterior area.



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Recently, a major reorientation oforthodontic thinking has occurred

regarding adult patients. Because of thefollowing reason :

1. Improved appliance placement techniques

2. More sophisticated and successfulmanagement of the symptoms associatedwith joint dysfunction.



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3. More effective management ofskeletal jaw dysplasia’s using advancedorthognathic surgical techniques

4. Increased desire of patients and

restorative dentists for treatment ofdental mutilation problems using toothmovement and fixed restorations ratherthan removeable prosthesis.



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Adult orthodontics

Adult orthodontics can mainly be dividedinto

Comprehensive treatment of adults

Adjunctive Treatment for AdultsCombined surgical and orthodontic

treatment



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Comprehensive treatment

The boundary between adjunctiveand comprehensive treatment is

indistinct.

Treatment that requires

a complete fixed appliance or

that is complex enough to require morethan 6 months for completion is

considered comprehensive.



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Comprehensive Treatment Plan

The treatment plan is a prospectivesequence of medical and dental

procedures designed to alleviate theprioritized list of problems.

For a favorable long-term prognosis, it

is important to direct treatment ateliminating or at least controlling theetiology of the problems.



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Alternate Treatment Plans

Constructed by arranging the teeth in aseries of drawings that reflect thetherapeutic options.

Way of communicating with patient regarding

• biologic considerations,

• treatment alternatives,

• potential compromises,

• probable consequences.



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Adult orthodontic TreatmentObjectives

The typical adolescent orthodontictreatment objectives

• dentofacial esthetics,• stomatognathic function,

• stability ,

• static and dynamic Class I occlusion

often may not be realistic or necessary for all

adult patients.



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Treatment in which adolescent goals arenot achieved is not necessarilycompromised

The mechanotherapy should satisfy the

objective of providing the minimal dentalmanipulation appropriate for the individualcase.

Adult orthodontic TreatmentObjectives…..



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Adolescent treatment objectives includingClass I occlusal goals can be considered

overtreatment for patients who also require• restorative dentistry,

• prosthetics,

• plastic surgery and

• other multidisciplinary dentofacial

corrections

Adult orthodontic TreatmentObjectives….



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ADDITIONAL ORTHODONTICTREATMENT OBJECTIVES

1. Parallelism of abutment teeth.

2. More favorable distribution of teeth.

3. Redistribution of occlusal and incisal forces.

4. Adequate embrasure space and proper

tooth position.

5. Acceptable occlusal plane and potential forincisal guidance at satisfactory vertical

dimension.



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ADDITIONAL ORTHODONTICTREATMENT OBJECTIVES…

6. Adequate occlusal landmark relationships.

7. Better lip competency and support.8. Improved crown/root ratio.

9. Improvement or self-correction ofmucogingival and osseous defects.

10. Improvement and self-maintenance of

periodontal health.

ADDITIONAL ORTHODONTIC TREATMENT



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OBJECTIVES… Parallelism of abutment teeth.

The abutment teeth must be placedparallel with the other teeth to permit

insertion of multiple unit replacement.

For full-arch splints, the posterior teethshould be reasonably parallel to

anterior abutments.




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OBJECTIVES…

Parallelism of abutment teeth…

Parallel abutments allow for betterrestorative retention

A restoration will have a better prognosis ifthe abutment teeth are parallel beforetooth preparation.

• does not require excess cutting ordevitalization during abutment preparation

• allows for a better periodontal response.




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OBJECTIVES…

More favorable distribution of teeth

The teeth should be distributed evenly forplacement of fixed and removableprostheses in the individual arches.

Moving the teeth to act as favourableabutments can reduce the need for distal

extension partial dentures or implants.They should be positioned so that

occlusion of natural teeth can be

established bilaterally between arches.




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OBJECTIVES… Redistribution of occlusal and incisal forces.

Cases with significant bone loss requireocclusal forces to be directed verticallyalong the long axis of the roots.

• Teeth can be moved orthodontically to morefavourable positions.

• If posterior teeth are missing, anterior teeth canbe positioned to allow favourable transfer offorce and can then be reshaped to functionas posterior teeth (supporting the verticaldimension .

ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES



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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Adequate embrasure space and properroot position

Allows for better periodontal health, especiallywhen the placement of restorations is

necessary.Anatomic relation of the roots is important in

the pathogenesis of periodontal disease,

interproximal cleaning,

placement of restorative materials.

Acceptable occlusal plane and



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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension.

To establish the acceptableocclusal plane for a mutilated

dentition exhibiting bite collapse,the Hawley bite plane is insertedwith the platform of the anterior

plane adjusted at a right angle tothe long axis of the lowerincisors.



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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension.

This allows a centric relation at anacceptable vertical relationship to be

maintained, while

tooth alignment and

movement of the teeth to a morefavorable position

to support the vertical dimensions and

occlusal loading takes place.

Acceptable occlusal plane and



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Acceptable occlusal plane andpotential for incisal guidance atsatisfactory vertical dimension…

If the vertical dimension is excessivepatient may complain of muscle

fatigue.

However when properly adjusted at thecorrect vertical height, the bite plane

will allow simultaneous bilateralneuromuscular activity.

A bl l l l d



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If supraerupted molars are present,

most extruded posterior segmentdetermines the potential for anorthodontic solution at an acceptablevertical dimension.

The unilateral orthodontic treatment of anaccentuated occlusal plane should beavoided; one side cannot be left extruded.

A bl l l l d



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Adult molars with amalgamrestorations and normal pulpal

recession often can be occlusallyreduced 2 to 4mm to achieve anacceptable occlusal plane level and

still allow for placement ofrestorations without the need fordevitalization.

A t bl l l l d



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In some of Class II, division I cases (when orthognathic surgery is

rejected) the lower incisors canbe advanced into a moreprocumbent position than the

usual orthodontic norm toestablish incisal guidance.

A t bl l l l d t ti l



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Acceptable occlusal plane and potentialfor incisal guidance at satisfactoryvertical dimension…

With the aid of bilateral posteriorrestorations, the incisors can be

stabilized when in relatively flaredpositions (IMPA 1050 to 1200).

In some Class III patients as well, the

maxillary incisors can be kept instable relation (even though moreflared than normal) with posterior

restorations.



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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Adequate occlusal landmarkrelationships.

For adult patients, transverse dimension ismost difficult to correct and maintainorthodontically, followed by sagittal andvertical.

• Posterior crossbites with severe transverse

skeletal dysplasis, not to undergo surgeryshould be positioned so that maxillarybuccal cusps contact the lower centralfossae with crossover for incisal guidance in

premolar area or canine positions



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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better lip competency and support.

Many adults have long upper lips thatpreclude significant maxillary

retraction.

In such cases retraction isrecommended to achieve lip

competency while maintaininglip support.



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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better lip competency and support…

Inadequate support may create achange of anteroposterior and vertical

position of upper lip and increasewrinkling.

This makes the face seem prematurely

aged and is a major esthetic concernof adults.



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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Improved crown/root ratio

In adult patients who have lost bone onindividual teeth, the ratio of crown to

root can be improved by reducing thelength of the clinical crown with the high-speed handpiece; as the tooth is eruptedorthodontically.

As the tooth erupts orthodontically thebone also follows the tooth so that the

bone support is not compromised.




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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Improvement or correction ofmucogingival and osseous defects…

Proper repositioning of prominent teeth inthe arch improves gingival topography.

In adults the goal should be to level thecrestal bone between adjacentcementoenamel junctions.

This creates more physiologic osseousarchitecture with the potential to correctcertain osseous defects.




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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Improvement or correction ofmucogingival and osseous defects…

Need for osseous and mucogingivalsurgery may be diminished by favorabletooth movement.

• During leveling stages, any teeth that haveerupted above the occlusal plane should

be grossly reduced occlusally; to preventposterior premature contact and occlusaltrauma, that can lead to bone loss oradverse changes in the supporting bony

architecture.




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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better self-maintenance of periodontalhealth.

The location of the gingival margin isdetermined by the axial inclination and

alignment of the tooth.Clinically improved self-maintenance of

periodontal health occurs with proper

tooth position.

Example: adult patients duringcorrection of bite collapse and

accelerated mesial drift




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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better self-maintenance of periodontalhealth…

Patients who need weekly periodontalmaintenance during initial leveling

phases of therapy may require lessfrequent scaling and root planning asperiodontal status improves with

tooth leveling and aligning.For better periodontal health, teeth

should be positioned properly over their

basal bone support.




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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Better self-maintenance of periodontalhealth.

In the nonsurgical management ofskeletal Class III and Class II

malocclusions, a delicate balanceexists between periodontallydesirable tooth positions and

achievement of other nonsurgicaltreatment objectives.



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ADDITIONAL ORTHODONTIC TREATMENT OBJECTIVES Esthetic and functional improvement.

The adult orthodontic treatment planshould provide acceptable dentofacial

esthetics and allow for improvedmuscle function, normal speech, andmasticatory improvements.

This is possible when a therapeuticocclusion is provided that enables theposterior teeth to support the vertical

dimensions.

Diagnosis and treatment



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Diagnosis and treatmentplanning

Collect data accurately

Analyze the data base

Develop problem list

Prepare tentative treatment plan

Di i d t t t



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Diagnosis and treatmentplanning…

Interact with those who are involved;discuss plans and options

clarify sequence;acquire patient acceptance

Create final treatment plan



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Chief Complaint base of the “diagnostic

tree”

• Gives an indication of the treatmentexpectations of the patient.

• Realistic treatment expectations are veryimportant in cases of adult orthodontictreatment .



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Psychological considerations

EXEPTIONAL PERSONALITYHIGHLY SUCCESSFUL ,OVERCOMPENSATE

FOR THEIR DEFORMITY

NO PROBLEMREASONABLE TREATMENT EXPECTATIONS

INADEQUATE PERSONALITY

USES DEFORMITY AS SHIELD FORWIDE RANGE OF SOCIAL ADJUSTMENT PROBLEMS

PATHOLOGICAL PERSONALITYSMALL DEFORMITY, BIG PROBLEM

ALMOST IMPOSSIBLE TO HELP



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Medical evaluation

Genetic problems

Acquired health problems

Calcium metabolism and bone mass

Medications

Psychologic factors.



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Clinical examination

Extraorally

Frontal symmetry,

Profile

Lip protrusion andcompetence.



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Intraoral examination

Soft tissue:

Periodontium (inflammation andloss of attachment caused bypockets, recession, and bone loss)

Pathologic condition of the mucosa

Cancer screening.



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Diagnosis and treatment planning…

Intraoral examination

Hard Tissues

The dentition should be evaluated for

operative,

endodontic, and

prosthodontic problems.



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PERIODONTAL DIAGNOSIS

The orthodontist must make an accurate

assessment of the patient’s potential forbone loss or gingival recession duringorthodontic tooth movement.

Tooth movement and clenching orgrinding instigated by movementinterferences, may lead to significant

bone loss.



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PERIODONTAL DIAGNOSIS…

Regaining control of periodontal inflammationis harder than controlling it from the

beginning.Every adult case should be closely

monitored with the periodontal specialist.

Appropriate management of several factorsis needed to prevent negative periodontalsequelae during orthodontic treatment



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Diagnosis and treatment planning… PERIODONTAL DIAGNOSIS…

These include:

1. Awareness and vigilance of the

orthodontist and the staff.

2. Awareness and vigilance of the patientmust be frequently reinforced.

3. Awareness of risk factors related toperiodontal breakdown.



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Risk factors

General Factors:

Family history of premature tooth loss(indication of immune system deficiencyin resistance to chronic bacterial

infection associated with periodontaldisease).

General health status and evidence of

chronic diseases (e.g. diabetes).



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Nutritional status

Current stress factorsLife stage of women

Local factors:

• Tooth alignment (e.g, marginal ridge,

cementoenamel junction relationship).



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Plaque indices

Occlusal loadingCrown-to-root ratio

Grinding, clenching habits(parafucntional activity)

Restorative status



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CLASSIFICATION OF PERIODONTALHEALTH OF ADULT PATIENTS

Incipient periodontal disease

Moderate periodontal disease

Advanced periodontal disease



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Incipient periodontal disease

Therapy prescribed

1. Scaling and curettage

2. Patient education for home care

3. 2 to 6 month maintenance intervals whilein fixed appliances

Provider General dentist



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Moderate periodontal disease

Therapy prescribed

1. Scaling

2. Curettage and periodontal surgery 6 to 8

weeks before orthodontics3.Orthodontic tooth movement



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4. 4 to 16 week maintenance intervalsduring orthodontic treatment

5. Periodntal reevaluation 12 weeksafter appliances are removed.

Provider

Periodontist and Orthodontist



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Advanced periodontal disease

Therapy prescribed

1. Scaling

2. Periodontal curettage(open-flap-clean-out)

3. Orthodontics

4. Periodontal reevaluation

5. Definitive osseous surgery



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6. Final restorative dentistry

7. Periodontal consideration reevaluated- Thisis done clinically with radiographs; checkmobility,perform probing and make softtissue assessment.

Provider Periodontist, orthodontist, generaldentist



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DIAGNOSIS OF TEMPOROMANDIBULARJOINT DYSFUNCTIONS

The signs and symptoms of TMD oftenincrease in frequency and severity duringadult treatment.

Thus, it is imperative that orthodontistsshould diagnose any TMD present anddetermine its etiology before starting the

orthodontic treatment.



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TMJ considerations

CLENCHING,GRINDING

(STRESS RESPONSE)

MUSCLE SPASMAND FATIGUE

INTERNAL JOINTPATHOLOGY

TMD SYMPTOMSPAIN

JOINT NOISELIMITED OPENING

Di i d t t t l i



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Diagnosis and treatment planning… Diagnostic records

A complete set of diagnostic records shouldbe obtained including

Casts

Radiographs IOPA

Panoramic

Cephalograms (optional)

Photographs



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Evaluation of the malocclusion.

Etiology of malocclusion.

In the absence of congenital anomalies orsignificant trauma most people with a fullcomplement of teeth have the genetic

potential to develop and maintain anormal occlusion.

Thus, the main environmental factors

causing malocclusions are:



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habits

functional compromises

soft tissue posture

developmental aberrations and trauma

periodontal disease

caries



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Cause of the malocclusion should be carefullyconsidered

Treatment should be directed at eliminatingor controlling the aberrant factors.

Thus, th e diagnosis is a prioritized list ofproblems based on a careful evaluation ofentire database.

Treatment Planning comparisons



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between adolescent and adultorthodontic patients

A through understating of the similaritiesand difference between adolescentand adult patient is required todevelop a less stereotyped and morecustomized treatment plan for adultpatients.

Several authors have identified what theyconsider the major differencesbetween adolescent and adult patient



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Treatment Planning Diagnostic between

adolescent and adult orthodontic patients…

Leavitt (1971): in adult patient there isno growth only tooth movement

Barrer (1977): stated that the adult unlikethe child is a relentless patient who willnot cover our deficiencies in skill or

our errors in the use of mechanicalprocedures by helpful setling in posttreatment.



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Treatment Planning Diagnostic between

adolescent and adult orthodontic patients…

Ackerman(1978) stated

For a child patient one occasionally

calls another specialist. On the otherhand it is a rare adult whom onetreats orthodontically without finding

it necessary to collaborate withanother specialist.

FACTORS IN SELECTION OF A



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TREATMENT PLAN :COMPARISONBETWEEN ADOLESCENT AND ADULT

A. Growth factors

B. Existing oral pathosis

1. Dental caries

2. Periodontal disease

3. Faulty restorations

4. TMJ adaptability

5. Occlusal interferences

6. Dental mutilation




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C. Biological considerations

1. Neuromuscular maturity

2. Rate of tooth movement

3. Periodontal susceptibility

D. Dentofacial esthetics




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E. Therapeutic approachesavailable

1. Orthopedics

2. Orthognathic surgery

3. Restorative dentistry

4. Combination treatment

5. Extraction controversy

6.

Anchorage potential

COMPARISON BETWEEN ADOLESCENT



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COMPARISON BETWEEN ADOLESCENTAND ADULT…

Growth factors

Adolescents

Because of growth an orthopedic optionis available; stable correction ofskeletal discrepancy is possible.

Sequence of difficulty of orthodonticcorrection(most to least) is vertical ,anteroposterior, transverse.

COMPARISON BETWEEN ADOLESCENT ANDADULT



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ADULT…

Growth factors…

Adults

No growth with minimal skeletal

adaptability; therefore surgicalprocedures are necessary for moderateto severe skeletal disharmonies;

Stable correction in skeletal transverseproblems requires surgically assistedrapid palatal expansion.




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ADULT…

Growth factors…

Adults…

• Mandibular deficiency : sagittal splitosteotomy and mandibular advancement;

• Mandibular excess : mandibular setback;

• Vertical maxillary excess with or without open

bite : Lefort osteotomy.

• Combination problems may requirecombination surgery depending on severity




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ADULT…

Growth factors…

FACTORS IN SELECTION OF ATREATMENT PLAN COMPARISON



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Existing oral pathosis

Dental caries

Adolescents More likely to have simplecarious lesions, but more susceptible tocaries

Adults More likely to have recurrent decay,restorative failures, root decay, and pulpal

pathosis.

COMPARISON BETWEEN ADOLESCENTAND ADULT



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AND ADULT…

Existing oral pathosis…

Periodontal disease

Adolescents

More resistant to bone loss, but highlysusceptible to gingival inflammation

AdultsHigher susceptibility to periodontal bone loss.

COMPARISON BETWEEN ADOLESCENT



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AND ADULT…


Faulty restorations

Adolescents

Few significant restorative problems

Adults

Frequent restorative problems witheconomic and treatment planningimplications




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AND ADULT…


TMJ adaptability

Adolescents

Small percentage with symptoms because ofhigh degree of TmJ adaptability; infrequentsymptoms

Adults

Frequent appearance of symptoms with

dysfunction




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AND ADULT…


Occlusal interferences

AdolescentsInfrequent cause of problem

Adults

Hightened ; may lead to acceleratedenamel wear with adverse change insupporting tissues.

COMPARISON BETWEEN ADOLESCENT AND



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COMPARISON BETWEEN ADOLESCENT ANDADULT…

Dentofacial esthetics

Adolescents

Reasonable concern frequently matched toseverity of condition

Adults

Concern occasionally disproportionate todegree of existing problem



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Biological considerations

Neuromuscular maturity

Adolescents Significant potential foradaptability of stomatognathic system,allowing a variety of biomechanical choices

( class II elastics)Adults mechanical options are limitedbecause of lack of neuromuscular

adaptability



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Rate of tooth movement

Adolescents

Predictable and rapid, particularly duringeruptive stages when permanent rootdevelopment is not yet completed

Adults

somewhat slower



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Periodontal susceptibility

Adolescents more resistant to bone loss as aresult of periodontal disease

• but highly susceptible to gingival inflamation.

Adults Higher degree of susceptibility to bone

loss as a result of periodontal disease,

• particularly evident during orthodontic therapymay need modification of mechanotherapy

Effects of reduced periodontal



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p

support

When bone has been lost same amount offorce produces greater pressure in PDLof a compromised tooth than a normallysupported one.

Greater the loss of attachment, smaller thearea of supported root and furtherapically the center of resistance




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p

support

The center of resistance of a single rootedtooth is approx. one tenth the distance

between apex and crest of bone. Inperiodontally compromised patient there isreduction in bone level and hence the center

of resistance shifts apically.




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p

support…

This affects moments created byforces applied to the crown and

moments needed to control rootmovement.

Lighter force and larger momentsare needed in such cases.



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Gingival esthetic problems

These are created by

1. Uneven display of gingiva

e.g. substituting a canine for missinglateral incisor

Elongating a tooth to compensate for

broken incisal edge .

Better to restore the incisal edge bycomposite.



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Gingival esthetic problems

2. Gingival recession after periodontalloss

Creates black holes between the

maxillary incisorsRemove interproximal enamel so that

the incisors can be brought closer

together.This moves the contacts gingivally

minimizing the open space between

the teeth.




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ADULT…

Therapeutic approaches available…

Dental mutilation

Adolescents early treatment control duringeruptive stages facilitate space closure without

prosthesis

•e.g, congenitally missing maxillary laterals ormissing second premolars.

Adults present with a number of missing teeth.

• More difficult to treat without prosthesis and

restorations.




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U

Therapeutic approaches available

Orthopedics

Adolescents About half require orthopedics

Adults Effective only in small percentage

Orthognathic surgery

Adolescents Major skeletal alterationsneeded in 1 to 5%

Adults major alterations needed in 10 to20%




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ADULT…


Restorative dentistry

Adolescents

Smaller percentage requires it,

when teeth are congenitally missing

frequently orthodontic therapy is useful inspace closure or space redistribution,thus avoiding the need for restorative

dentistry.




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ADULT…


Restorative dentistry…

Adults

Integrated restorative plan can greatlyreduce duration of fixed appliance

treatment

Frequently required for space reopeningwhere teeth have been lost and

for abutment preperation and stabilization

of occlusal relationship;




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ADULT…


Combination treatment

Adolescents Uncommon

Adults Required in 80% of casesExtraction controversy

Adolescents a treatment plan of fourpremolar extraction is used frequently toresolve crowding and protrusions,

space gaining techniques are also available.

COMPARISON BETWEEN ADOLESCENTAND ADULT…



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Extraction vs nonextraction therapy

Adults

Four premolar extractions are used lessfrequently to resolve crowding, upperpremolar extractions are a common

alternative , asymmetric extraction and

stripping of over bulked restorations.




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ADULT…


Strategic extractions

Adults Irreversible damage to periodontal

tissues or to adjacent teeth may forceorthodontists into unusual treatment plansfor adults,

Careful analysis may lead to strategicextraction to solve alignmentproblems, as well as to eliminate

existing damaged teeth




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ADULT…


Anchorage potential

Adolescent more frequent incorporation

of headgear to maximize anchorage andretraction of the anterior teeth.

Headgear cooperation Greater




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U


Adults

fewer adult cases will be categorized as

maximal anchorage problems,

implants in conjunction with restorativedentistry ,

several molar distalization techniques arebeing developed as options to avoidheadgear wear with adults.




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Adults

Frequent problems involving anterior and

posterior teeth require restorativecommitment for treatment planning

supraeruption is a problem in posterior bite

collapse,

Occlusal plane management is crucial.



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Sequence of treatment

It can be given in the following steps

Comprehensive treatment plan

Stage 1: disease control

Stage 2: reestablish occlusion

Stage 3: definitive periodontic orrestorative procedures.

Stage 4. : maintenance

COMPLICATIONS IN ADULT



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COMPLICATIONS IN ADULTORTHODONTIC TREATMENT

Medical Concerns

The medical history should be updated

regularly.

If significant medical problems occur,confer with the patient’s physician

regarding continuing or interruptingorthodontic treatment.

COMPLICATIONS IN ADULT ORTHODONTICTREATMENT…



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Medical Concerns…

Some problems e.g. recent myocardialinfarction may require interrupting orterminating all elective care.

Thus, careful monitoring of medicalfactors is essential for effective

management of adult patients duringadjunctive orthodontic treatment or aspart of a comprehensivemultidisciplinary treatment plan.

COMPLICATIONS IN ADULT ORTHODONTICTREATMENT



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TREATMENT…

Poor Cooperation

Treatment with fixed mechanics iscontraindicated until the patient hasdemonstrated the ability to maintaingood oral hygiene.

Oral hygiene and the periodontalcondition should be monitored at eachappointment.




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TREATMENT…

Caries

Incipient and undiagnosed caries in course oftreatment can lead to compromises in

orthodontic results.

§ No previous caries Panoramic radiograph only

§ Previous caries Obvious pathologyAdd bitewing radiographs

§ Deep caries Add periapical radiographs




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TREATMENT…

Technical Problems

Panoramic radiographs and intraoralradiographs should be taken at every 6-

months and cephalometricradiographs should be taken every 12months.

Superimpositions of tracings foridentifyuing complications anddetermining if the treatment can progress

as lanned




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TREATMENT…

Temporomandibular disorders

For a minor problem there may be no need forspecific dental treatment.

Treatment includesIdentifying the bad habit and eliminating it.Rest with limited function

ReassuranceIf there is a clear relationship of symptoms toorthodontic changes in occlusion, theorthodontic treatment should be considered.



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Segmented arch technique in adults

Helpful in controlling the forcemagnitude in adults as it involvescreating a stable anchorage unit

consisting of several teethconnected to act as a singlemultirooted teeth so the force is

distributed over a larger area.

This is more important in periodontallycompromised cases.

Fi i hi d i



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Finishing and retention

Positioners are rarely indicated asfinishing devices in adult patients withperiodontal disease.

In patients having significant bone lossand tooth mobility, both short term andlong term splinting is required.

Treatment is finished with archwires andthen stabilized immediately with

retainers

ADULT ORTHODONTIC

PATIENT TYPES



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PATIENT TYPES

Case type

Physiologicocclusion

(exhibits no

signs of

existing

pathosis)

Characteristic

of major

problem areas

• Mild dentalmalalignment

• normalocclusion ormalocclusionthat isestheticallyacceptable

Associated

healthy

systems

•Occlusalstability

•No decayand lack ofocclusalwear

•Psychological balance

Treatment

OrthodontistConsultationand patienteducation (i.e.,

presentconditionrequires noorthodontictreatment).

ADULT ORTHODONTIC

PATIENT TYPES



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PATIENT TYPES

Case

type

Major

problem

areas

Associated

healthy systems

Treatment

Physiol-ogic

occlusion

(exhibits

no signsof

existing

pathosis)

•TMJasymptomatic

•No speechimpairment

•No occlusalawareness

•No functional

disorders

•Relieve concern ofreferring dentistthat conditionprobably won’t get

worse

•Make patientaware of existinghealth levels

ADULT ORTHODONTIC

PATIENT TYPES



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PATIENT TYPES

Case type Major

problem

areas

Associated

healthy

systems

Treatment

Physiologic

occlusion

(exhibits no

signs of

existing

pathosis)

•Documentpresentcondition

ADULT ORTHODONTIC

PATIENT TYPES



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PATIENT TYPES

Case type Major

problem

areas

Associated

healthy

systems

Treatment

Psychologicaldisorientation

•Concernabout minordentalconditionfar

exceedingrealsignificanceof the

problem

•Dentitionaligned

•Skeletal

balance

•TMJ

asymptomatic

•Periodontium

healthy

•Make patientaware of the

dental health

condition

•Psychological councelling

as needed

ADULT ORTHODONTIC

PATIENT TYPES



113

PATIENT TYPES

Case type Major

problem areas

Associated

healthy

systems

Treatment

Correctiveorthodontics

•Mild tomoderatedental-skeletaldisharmony

•Unsatisfactorydentofacialesthetics

•Psychologicbalance

•Skeletal WNL

•TMJ

asymptomatic•No toothreplacement

required

Restorativedentist orhygienist

Caries andinflammatorycontrol

ADULT ORTHODONTIC

PATIENT TYPES



114

PATIENT TYPES

Case type Major

problem

areas

Associated

healthy

systems

Treatment

Corrective

orthodontics

Orthodontist

Comprehensiveorthodontictherapy

(extraction/nonextraction)

Dentist orhygienist

ADULT ORTHODONTIC

PATIENT TYPES



115

PATIENT TYPES

Case type Major

problem

areas

Associated

healthy

systems

Treatment

Correctiveorthodontics

Scaling and curettageat 3 to 6mm intervals

Orthodontist

•Retention

•Periodic monitoringof oral health needs.

ADULT ORTHODONTIC

PATIENT TYPES



116

PATIENT TYPES

Case type Major problemareas

Associatedhealthy

systems

Treatment

Orthognathic

surgery

•Dental-skeletaland/orneuromusculardisharmoniesof moderate to

severe degree

Restorativedentist

Caries andinflammatorycontrol

Orthodontist

Presurgicalintra-archorthodontic

re aration

ADULT ORTHODONTIC

PATIENT TYPES



117

PATIENT TYPES

Case type Major

problem

areas

Associated

healthy

systems

Treatment

Orthognathicsurgery

Reevaluate recordsOral surgeon

Orthognathic surgeryto correct skeletal-

dental disharmony Orthodontist

post surgicalorthodontic therapy

ADULT ORTHODONTIC

PATIENT TYPES



118

PATIENT TYPES

Case type Major

problem

areas

Associated

healthy

systems

Treatment

Orthognathic

surgery

Retention records

Oral surgeon orplastic surgeon

Adjunctive surgical

procedures

(genioplasty,rhinoplasty, facelift)

ADULT ORTHODONTIC

PATIENT TYPES



119

PATIENT TYPES

Case type Major problem

areas

Associated

healthy

systems

Treatment

Periodontallysusceptible •Dental-skeletalmalrelationshipwith moderateto advancedbone loss

•Primarysecondaryocclusal traumamay be present

•Emotionalbalance

•TMJasymptomatic

•Othersystems maybe affectedsecondarily

Restorativedentist orhygienist

Caries

andinflammatory

control

ADULT ORTHODONTIC

PATIENT TYPES



120

PATIENT TYPES

Case type Major

problem

areas

Associate

d healthy

systems

Treatment

Periodontallysusceptible

Periodontist orhygienist

•Maintenance of rootsurface preparation

•Subgingival removalof microbiota

•Gingival graftingprocedures

ADULT ORTHODONTIC

PATIENT TYPES



121

PATIENT TYPES

Case type Major

problem

areas

Associated

systems

Treatment

Periodontallysusceptible

Orthodontist

Comprehensivetherapy

Selective grinding

Retention

Periodontist

reevaluation anddefinitive periodontal

procedures

ADULT ORTHODONTIC

PATIENT TYPES



122

PATIENT TYPES

Case type Majorproblem areas

Associatedsystems

Treatment

TMJdysfunction •Dental-skeletalmalrelationship

with jointdysfunction

•TMJsymptoms

Othersystemsmay beaffected

OrthodontistDiagnosticappliance toachieve relief ofsymptoms and todetermine degreeof skeletaldisharmony andneed for further

diagnosis

ADULT ORTHODONTIC

PATIENT TYPES



123

PATIENT TYPES

Case type Major

problem

areas

Associated

systems

Treatment

TMJdysfuncti

on

Psychotherapist

Counseling asneeded/stress reductionprogram

Orthodontist

•Occlusal therapy

•Comprehensiveorthodontics

ADULT ORTHODONTIC

PATIENT TYPES



124

PATIENT TYPES

Case type Major

problem

areas

Associated

systems

Treatment

TMJdysfunction

•Selective grinding

Oral surgeon

Surgical management

Restorative dentistRestorative dentistry ifrequired



125

Case type Majorproblem

areas

Associatedsystems

Treatment

Enamel wear

beyond that

expected for

chronologic

age

•Heavy

musculature(mandibulardeficiency)

•Dental-

skeletal deep-bite

Other

systemsmay beaffectedsecondary

Restorative

dentist

•Caries orinflammatorycontrol

•Occlusalcontrol

ADULT ORTHODONTIC

PATIENT TYPES



126

PATIENT TYPES


areas

Associatedsystems

Treatment

Enamel

wear

beyond

that

expectedfor

chronolog

ic age

OrthodontistComprehensiveorthodontics

•Periodontal surgery

•Crown lengthening•Restorativedentistry if required

ADULT ORTHODONTIC

PATIENT TYPES



127

PATIENT TYPES

Case type Major

problem areas

Associated

systems

Treatment

Dentalmutilations

•Prematureloss of teeth orcongenitallymissing teeth

•May involvebite collapseand loss ofvertical height

Associatedsystems WNLbut may beaffected assecondary

Restorativedentist

•Caries andinflammatory

control•Occlusalcontrol withmodifiedtreatment goals

ADULT ORTHODONTIC

PATIENT TYPES



128

PATIENT TYPES

Case type Major

problem

areas

Associated

systems

Treatment

Dentalmutilation

Comprehensiveorthodontic treatmentwith modified goals

Periodontist

Adjunctiveperiodontal treatment

restorative dentistry

Tooth replacement

ADULT ORTHODONTIC

PATIENT TYPES



129

PATIENT TYPES


areas

Associatedsystems

Treatment

Borderlinesurgical case •Dentofacial

imbalance ofmoderateseverity

•Basal bone

discrepancyin both jawscontribute todentofacial

imbalance

•Adequate

attachedgingiva fordentalcompensation

in each arch•Patientacceptsdentofacial

imbalance

Restorativedentist

•Caries andinflammatorycontrol

•occlusalguard tocontrol wear

ADULT ORTHODONTIC

PATIENT TYPES



130

PATIENT TYPES

Case type Major

problem

areas

Associated

systems

Treatment

Borderlinesurgical

case

Imbalancelooksgreaterthan it is

•Orthodontist •Differentialdiagnosis of skeletalcomponent to the

problem•Deprogram musclesand reevaluate withmounted study

models

ADULT ORTHODONTIC

PATIENT TYPES



131

PATIENT TYPES

Case type Major

proble

m areas

Associated

systems

Treatment

Borderlinesurgical

case

•Comprehensiveorthodontic treatment

Oral surgeon

•Evaluate records andprovide surgical opinion

•Advise patient of risksand benefits of surgery

ADULT ORTHODONTIC

PATIENT TYPES



132

PATIENT TYPES

Case type Major

problem

areas

Associated

systems

Treatment

Dental

mutilations

Interdisciplin

ary dental

therapy

(IDT).

C l i



133

Conclusion

Thus it can be concluded that adultorthodontic treatment though

having the same basic goals andbiomechanics has certain importantdifferences from the conventional

adolescent treatment that shouldbe carefully evaluated .



134

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Hom BM, Turly PK: the effects of space closureof the mandibular first molar area in adults, AJO

85:457-469,1984.

Roberts WE et al : Rigid implant anchorage toclose a mandibular first molar extraction site,

JCO 28 693-704 1994



Folio J: Orthodontic therapy in juvenile periodontitis:clinical and microbiological effects.AJO, 87:421-431, 1985.

Kusy RP et al : analysis of moment to force ratios inthe mechanics of tooth movement, AJO90: 127-131, 1986.

Proffit WR.:Contemporary Orthodontics: thirdeditionG b TM V d ll O th d ti C t

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